Report on HIV Partner Notification Activities 2004

Background:

On June 1, 2000, the New York State Department of Health (NYSDOH) implemented the HIV Reporting and Partner Notification Law passed in 1998. The law enhanced the existing AIDS case reporting system by adding reporting of newly diagnosed cases of human immunodeficiency virus (HIV) infection, HIV-related illness and AIDS by health care providers and laboratories to the State Commissioner of Health. The law also mandated reporting of known contacts of persons with newly diagnosed HIV and AIDS to allow for the provision of partner notification assistance. The implementing regulations indicate that all newly diagnosed cases of HIV infection and any known contacts reported by physicians merit priority consideration for partner notification. This report covers information on the partner notification assistance provided during 2004, and includes multi-year comparison charts for selected partner identification and notification outcomes.

Program Activities/Methods:

Operationally, partner notification activities outside New York City are conducted by a combination of NYSDOH and county health department staff, with staff of the New York City Department of Health and Mental Hygiene (NYCDOHMH) conducting follow-up on New York City cases. In New York City, the NYCDOHMH Contact Notification Assistance Program (CNAP) oversees and conducts partner notification activities.

New York State cases residing outside of New York City (NYC) are referred for partner notification evaluation to the 12 participating county health commissioners and NYSDOH regional PartNer Assistance Program (PNAP) staff. In New York State outside NYC, provider reports and laboratory reports are distributed electronically from the NYSDOH central office using a confidential and secure tracking system. Reports are assigned to the county health department or NYSDOH regional office responsible for conducting partner notification follow-up.

PNAP staff, who are a mix of state and participating county staff, routinely contact the health care provider regarding reports of newly diagnosed HIV infection for the purpose of offering voluntary partner notification assistance. PNAP staff also contact the providers regarding reported cases of HIV illness and AIDS where the provider has listed known contacts or requests assistance. This is a consultation that enables the public health worker to confirm the diagnosis, update information about the index case (and partners' status), and to discuss information the physician has that may facilitate contacting the index case to discuss partners.

In addition to partner notification activities initiated through HIV reporting, there are a limited number of partner notification referrals which fall outside the system established by the reporting law. Examples include referrals from other jurisdictions/states where a New York State partner has been identified, index cases who tested anonymously who later seek voluntary partner notification assistance from a local health department, or continuing partner notification requests for AIDS cases diagnosed before the law's implementation (and therefore not newly reportable).

Table 2 summarizes the status of partner notification for partners identified on the provider report form at the time the provider report was submitted. Statewide, 38% of these partners were reported with a status indicating the notification had already been completed. This included confirmed notifications (provider performed the notification, confirmed that the patient completed the notification, or confirmed that the partner already knew his/her own HIV+ status) and unconfirmed notifications (patient states he/she has notified partner, patient states partner already aware of own HIV+ status). A significant number of providers (35%) in New York State outside NYC did not provide the requested partner assistance status code on the provider report form mailed in to NYSDOH. For New York City, where the forms are picked up in person by NYCDOHMH surveillance staff (who have the opportunity to check with the provider immediately on any missing information), the percentage with a blank status code is much smaller (1%). For New York State outside NYC, approximately one-fourth of the partners without a status code were situations where the provider had no name for the partner, and was listing a partner simply as UNK, or unknown, so no partner assistance status code was warranted. While it is unclear why providers left the code blank for other partners, PNAP staff were able to follow-up with the provider and/or patient to ascertain the status of discussion about partners and specific notification plan for all but two of the other partners where the code was initially left blank.

Table 3 presents the number, source and initiation status of partners identified during 2003 and 2004. Approximately 75% of these partners lived in New York City and one quarter lived in New York State outside NYC. Statewide, the majority of partners (75%) continued to be identified by the time of submission of the initial provider report. A sizeable increase was seen in 2004 in the number of additional partners elicited by the PNAP/CNAP programs in follow-up to reports submitted. Initiation status is included because partner follow-up cannot even be attempted when such limited information is provided that one could not possibly identify the partner. For example, providers may list a partner on a provider report form with only a first name, "anonymous" or "unknown" in the name field, and provide no other information for the partner. If no additional information can be attained on follow-up with the provider and/or patient, that partner is considered to have insufficient information to initiate (a CDC definition) or consider for follow-up. Those partners are shown in Table 3, but since notification could not even be attempted, they are not included in the subsequent Tables 4 and 5, which reflect notification outcomes.

Table 4 presents the outcomes for PNAP and CNAP initiated partners, and provides an opportunity to compare trends across years. As shown, 1,665 or 66% of all initiated partners were reported as having been notified in 2004 (79% of partners in New York State outside NYC, and 62% of NYC partners) by the time all follow-up was completed. Statewide, approximately equal numbers were notified by the health department (22%) and the patient (21%), with situations where the partner already knew their own HIV+ status also fairly common (13%).

New York State outside NYC had a higher percentage of the health department notifications (34% vs. 18%), and New York City reported a somewhat higher level of partners being notified by the patient/index case (24% vs. 14%).

Table 5 presents the reasons some partners were either not notified or not confirmed as notified. Approximately one-third of initiated partners were not known to be notified (21% in NYS outside NYC and 38% in NYC). In 2004, one percent (1%) of notifications statewide were deferred because of domestic violence (DV) concerns, a level close to that of prior years. The DV protocol requires immediate referral to needed services and delineates a follow-up process to determine if and when the notification can safely occur.

Summary and Discussion:

In New York State, there were 1,665 sex or needle-sharing partners of persons with newly diagnosed HIV infection, HIV illness or AIDS known to be notified of their exposure in 2004. Partner notification can help people understand they may be at risk of HIV infection, and assist in linking them to counseling and testing services.

It is also evident that we need to better understand why almost 75% of cases have no identified partners at the time all follow-up is complete, a trend that is different from that seen in some other states. PNAP/CNAP referral is a voluntary process, except for required physician reporting of partners known to them. There will inevitably be some patients who decline to discuss partners or do not want or need assistance. It is important that all patients understand the importance of partner notification, and that appropriate assistance, including easy access to PNAP/CNAP services, is made available.

In the last several years, there has been increased attention on research on effective partner notification strategies. In summarizing current knowledge in its 2004 guidance document CDC states: "Although some persons initially prefer to inform their partners themselves, many clients often find this more difficult than anticipated. Furthermore, notification by health department staff seems to be substantially more effective than notification by the infected person."1 It will also be important to continue to incorporate information about the relative effectiveness of different notification approaches into ongoing efforts to educate providers.

Table 1

Number of Cases With Any vs. No Partners* Cumulative Trends 2002 to 2004

Location

Number of partners per case

2002

2003

2004

Cumulative2002 to 2004

N

%

N

%

N

%

N

%

* Includes partners listed on provider reports and partners for cases identified with PNAP/CNAP assistance in follow-up. PNAP assignments include some cases that may not be new HIV infection. Reflects corrected cells for New York State Totals line of 2002-2003 report (New York State Total percentages and all other cells in that report were correct.)

New York State Total

No partner

5,851

75%

4,909

73%

4,927

74%

15,687

74%

1 or more partner/s

1,994

25%

1,857

27%

1,752

26%

5,603

26%

<7,845

<6,766

<6,679

<21,290

New York City

No partner

4,730

76%

3,880

74%

3,978

75%

12,588

75%

1 or more partner/s

1,454

24%

1,333

26%

1,341

25%

4,128

25%

<6,184

<5,213

<5,319

<16,716

Rest of New York State

No partner

1,121

67%

1,029

66%

949

70%

3,099

68%

1 or more partner/s

540

33%

524

34%

411

30%

1,475

32%

<1,661

<1,553

<1,360

<4,574

Table 2

Status of Partner Notification at Time of Submission of Initial HIV/AIDS Provider Report Form (2004)

Notification Status of Partner As Indicated by Provider onProvider Report:

Region

New York State Outside NYC1

New York City

Total New York State

Number

Percent

Number

Percent

Number

Percent

1 For New York State Outside NYC, only in-region partners shown. A limited number of additional partners that came in on upstate provider reports were New York City residents and referred to NYCDOHMH.

2 The Contact Notification Assistance Program (CNAP) provides services in New York City; the PartNer Assistance Program (PNAP) provides services in New York State outside of New York City.

Notified by Provider

15

4%

53

3%

68

3%

Provider Confirmed Patient Has Notified Partner

23

7%

169

9%

192

9%

Provider Confirmed Partner Already Knows Own HIV+ Status

25

7%

75

4%

100

5%

Patient States S/he Has Notified Partner (Unconfirmed)

28

8%

259

14%

287

13%

Patient States Partner Already Knows Own HIV+ Status (Unconfirmed)

16

5%

168

9%

184

8%

Notification in Progress

26

7%

86

5%

112

5%

Notification Plan Undetermined

10

3%

139

7%

149

7%

Domestic Violence Risk

4

1%

14

1%

18

1%

Other Mitigating Circumstances

-

-

372

20%

372

17%

Request CNAP/PNAP2 Assistance

80

23%

484

26%

564

25%

Already Referred to PNAP/CNAP

1

-

3

-

4

-

Attempted, partner declined

-

-

25

1%

25

1%

Blank (No Status Noted)

125

35%

12

1%

137

6%

<353

<100%

<1,859

<100%

<2,212

<100%

Table 3

Number, Source, and Classification of Partners Identified 2003 and 2004

Location

Partners

2003

2004

1 Includes additional unduplicated partners identified by health department staff in follow-up to provider or lab reports, and any partners referred by other jurisdictions (e.g., from other states, or between NYCDOHMH and NYSDOH) or through mechanisms outside HIV reporting. For example, while in 2004 there were actually 394 additional partners identified by PNAP, those that are NYC residents (N=34) were referred to CNAP via the NYSDOH inter-jurisdiction desk, and thus are included only in the New York City category of the above table. All states/jurisdictions share a standardized protocol used to share information on partners needing follow-up outside their own jurisdiction, by telephoning that information to a designated contact (who ensures the information is handled confidentially) in each state/jurisdiction. New York State and NYC are considered separate jurisdictions by CDC.

2 Some reported partners lacked sufficient information to initiate for partner follow-up (e.g., no name or partial name, unable to complete Domestic Violence screen, no address/locating information). Total partners initiated is the number of partners identified minus partners with insufficient information to initiate follow-up.

Table 5

Partners Not Known to be NotifiedCumulative Trends 2002 to 2004

Location

Status

2002

2003

2004

Cumulative2002 to 2004

N

%

N

%

N

%

N

%

1 DV Risk = Domestic Violence Risk

2 The "Other" category includes notifications that could not be conducted due to mitigating circumstances such as: it could not be confirmed that the mandatory DV screen had been completed on a partner reported by a non-health department provider (and the patient was not available for re-interview), partner lived out of state and NYS did not hear back from the other jurisdiction what follow-up was achieved, partner lived in another country for which no inter-jurisdictional relationship exists.